Aim of review. To present data of clinical trials, systematic reviews and metaanalyses which allow to optimize eradication therapy of Helicobacter pylori (H. pylori) infection. Summary. Standard triple therapy including proton pump inhibitor (PPI), clarithromycin and amoxicillin is the first­line treatment for H. pylori eradication. At prescription of standard triple therapy various measures increasing its efficacy should be utilized. Classical fourcomponent bismuth tripotassium dicitrate­based treatment or quadrotherapy without bismuth including PPI, amoxicillin, clarithromycin and metronidazole may be alternative options for the first line eradication therapy. Quadrotherapy with bismuth tripotassium dicitrate is applied as the basic mode of second line therapy at failure of standard triple therapy. Alternative mode of the second line therapy includes PPI, levofloxacin and amoxicillin. Levofloxacin­based triple therapy can be prescribed only by specialist in gastroenterology at strict indications. Third line therapy is personalized according to the choice of the previous treatment modes. The choice of H. pylori eradication therapy in the Russian Federation is based on empirical approach. The rate of clarithromycin resistance of H. pylori strains in Russia does not exceed 15% in the majority of regional studies. There are data indicating absence of significant metronidazole resistance of H. pylori and low level of double clarithromycin and metronidazole resistance. Efficacy of H. pylori eradication therapy may be enhanced by increasing treatment duration to 14 days. Prescription of new generation PPI or increase of PPI dose are targeted to provide the maximum acid suppression, highly important for successful H. pylori infection eradication. Additional prescription of bismuth tripotassium dicitrate, probiotics or rebamipid increases efficacy of antihelicobacter therapy. Significant decrease of adverse events rate at H. pylori eradication treatment is reached at combined prescription of probiotics. Rebamipid may potentiate reparative processes in the stomach mucosa. Conclusion: Methods of H. pylori eradication optimization can be applied for enhancement of both standard triple therapy and other concomitant treatment modes, and the combination of these methods provides best result for the given patient.

Aim of review. To present the literature data on efficacy of the diet with decreased content of fermentable oligo­, di­ and monosaccharides and polyols (low FODMAP diet) for irritable bowel syndrome (IBS) treatment. Summary. The role of fermentable carbohydrates in development of IBS symptoms is discussed, the basic principles of low FODMAP­diet, its advantage and shortcomings are reviewed. Conclusion. Short­chain carbohydrates cause increased colonic gas production, influence large intestinal motility, exert osmotic effect that promotes development of IBS symptoms. Low FODMAP­diet reduces symptom severity and can be applied for IBS treatment.

Aim of investigation. To analyze dynamics of metabolic changes in cells of epithelium and mucosal glands of different stomach regions at mechanical acute smallintestinal obstruction (ASIO). Material and methods. The experimental part was carried out at 33 mature outbred dogs of both genders with body weight of 17-20 kg in compliance to the «Guide for the Care and Use of Laboratory Animals» (National Institute of Health - NIH, Bethesda, USA) and «Rules studies with experimental animals», approved by ethical committee of Burdenko Main Military Clinical Hospital of Ministry of Defense of the Russian Federation. Metabolic processes in cells of epithelium and stomach mucosal glands were studied by Einarson method of total nucleic acids detection. Test results were estimated by quantitative microspectrophotometry and computer software allowing to define the number of the area units of the study object occupied by cytochemical reaction products. Results. Obturation and strangulation ASIO dynamics result in decrease of metabolic processes leading to reduction of mucosal proliferative activity and suppression of regenerative capacity. At the same time metabolism of epitheliocytes of coating layer and cervical part cells and cells of cambial fundic part of glands is suppressed most significantly, at preservation of metabolic processes of zymogenic main cells of mucosal glands (pepsinogen­producing cells), i.e. generating aggressive factor. Both at acute strangulation and acute obturation smallintestinal obstruction the most pronounced morphofunctional changes of the stomach mucosa within disease development were observed in the antral region that explains the most frequent localization of acute ulcers in this area. Conclusions. Suppression of metabolic processes of epithelial cells of coating layer and cells of cervical and fundic parts of the glands at preservation of main cells metabolism causes reduction of mucosal preoperative activity and may cause suppression of regenerative capacity and decrease of protective function.

Aim of investigation. To study lipid composition of blood and bile at diabetes mellitus (DM) of the 1st and 2nd type. Material and methods. Overall 70 patients with the first type DM, 67 patients with the second type DM, 44 patients of the control group #1 and 43 patients of the control group #2 were investigated. All patients underwent diagnostics for the presence of DM and cholelithiasis, blood lipid levels and blood­to­duodenal bile ratio was assessed by biochemical methods. Results. Patients with type II DM and cholelithiasis had total cholesterol level in blood serum 25% higher, triglyceride level - 80% higher and Thomas­Hofmann index in duodenal bile portion B 20% higher, than patients was gallstone disease and type I DM. Conclusions. Type II DM is followed by more pronounced lipidemia and increase in bile cholesterol saturation, type I DM, but the latter is also associated with lipid metabolism disorders and the risk of gallstone disease development.

Aim of the study. To estimate efficacy and safety of 3D mode of interferon­free therapy in patients with subcompensated liver cirrhosis (LC) of HCV etiology (genotype 1b). Material and methods. Original study included the data of 66 patients (26 men and 40 women) with subcompensated LC of HCV etiology (genotype 1b) who underwent interferon­free therapy by ombitasvir/paritaprevir/ritonavir, dasabuvir and ribavirin for 12 weeks (the latter was cancelled at receiving the new data on treatment efficacy after 4 weeks of therapy) in September, 2015, before the drug instruction was updated. Mean age of patients was 56.4±10.0 years. At onset of etiological therapy 21 patients (31.8%) had Child­Pugh score of 9, eleven patients (16.7%) had Child­Pugh 8, 34 patients (51.5%) had Child­Pugh 7. The causes of inefficacy of previous modes of combined antiviral therapy (CAT) included absence of virologic response in 43.9% of the cases, recurrence of HCV replication - in 30.3%, virological breakthrough - in 16.7%, development of serious adverse effects - in 9.1%. Taking into account the change of the group quantity during the course of therapy because of treatment cancellation for safety reasons and the subsequent assessment of its efficacy in patients with early treatment cancellation, the modified «intent­to­treat» (ITT) analysis was the basic method of results evaluation. Along with that «per protocol» (PP) analysis was carried out as well. Results. During the treatment course aviremia in 14 days was achieved in 53.8% of patients (in 35 patients of 65), prompt virologic response - at 79.7% (in 51 of 64 patients). All patients underwent complete 12 week course of CAT (n=60) and those for whom treatment was canceled for safety reasons (n=3) - in terms from 14 to 30 days - sustained virologic response (SVR) in 12 weeks and SVR in 24 weeks was registered. The assessment of liver function compensation degree in 6 months after CAT termination demonstrated 3 to 4 points reduction of the Child-Pugh Score in 21 patients (33.9 %), 1 to 2 points in 35 patients (56.5 %). According to the MELD score the clinical improvement was achieved in 66.1% of patients. The early treatment termination was caused by progression of hepatic encephalopathy symptoms and/or jaundice development (4 cases). Most cases of the progression­related treatment termination due to liver failure were reversible after CAT interruption. Three lethal outcomes after the early treatment termination and 1 patients death in follow­up period were registered. Conclusion. Antiviral therapy in 3D mode for subcompensated LC is highly effective not only in those patients who received complete treatment course, but also in those with early treatment secession. Profiling of 3D therapy safety demonstrated that development of serious adverse effects during the treatment is comparable to outcomes at natural course of subcompensated LC in the absence of etiological therapy.

Aim of publication. To present the latest data on adequate diagnostic methods, treatment approaches and features of rational pharmacotherapy of gastroesophageal reflux disease (GERD) based on the principles of evidence­based medicine to general practitioners. Summary. The prevalence of GERD occupies the first place of other gastroenterological diseases. The heartburn that is a leading GERD symptom is present at 20-40% of the population of developed countries. The prevalence of GERD in Russia ranges 18­46%. Diagnosis of GERD early stages is based on the primary appealability and clinical presentation evaluation. Esophagogastroduodenoscopy (EGDS) gives the chance to define the presence of reflux esophagitis, to estimate severity grade, to reveal development of esophageal epithelium columnar metaplasia. At the refractory course (lack of conclusive clinical and endoscopic remission within 4-8 wks of treatment by standard dose of proton pump inhibitor - PPI), and development of complications (strictures, Barret's esophagus) examination within specialized hospital or gastroenterological clinic is required, including their out­patient departments. Under certain indications the patient should undergo EGDS with esophageal biopsy and histological examination of biopsy specimens to rule out the Barret's esophagus, esophageal adenocarcinoma and/or eosinophilic esophagitis; intraesophageal 24­hour pH­metry or pH­impedance measurement; high resolution esophageal manometry; X­ray study of the esophagus and stomach. The treatment of GERD has to be individualized according to the pattern and severity of clinical symptoms. The goal of treatment is symptom relief, at erosive esophagitis - healing of erosions and complication prevention, at Barret's esophagus - prophylaxis of disease progression and dysplasia and adenocarcinoma development. Nowadays PPIs are considered as the most effective and safe agents for GERD treatment. PPIs are applied for the long­term baseline treatment (no less than 4-8 wks) and maintenance therapy (6-12 months). Intake of alginates is pathogenically reasonable therapeutic approach for reduction of «acid pocket» and acid neutralization in the area of gastro­esophageal junction in GERD patients by formation of mechanical barrier raft which prevents reflux of the stomach content into the esophagus. Antacid monotherapy is recommended for the cases of rare heartburn which is not accompanied by esophagitis and in complex modes of GERD treatment for achievement of rapid symptom relief. Adsorbents are applied as monotherapy at non­ erosive reflux disease, and as a component of comprehensive GERD treatment, especially of the cases of mixed (acid + biliary) refluxes. Prokinetic drugs promote recovery of a normal physiological state of the esophagus, controlling the pathogenic mechanisms of GERD, reducing the number of transient lower esophageal sphincter relaxations and improving esophageal clearance due to stimulation of the lower gastrointestinal motor function. Prokinetics can be applied as a component of comprehensive treatment of GERD along with PPI. Anti­reflux surgery is indicated in complicated cases (recurrent bleeding, peptic esophageal strictures, development of Barret's esophagus with high­grade epithelial dysplasia, frequent aspiration pneumonias). Surgical treatment of GERD is more effective in patients was typical manifestations and positive treatment response to PPIs. Conclusion. Implementation of clinical guidelines can promote improvement of healthcare quality for GERD patients and prevent complications, in particular if terms of treatment will be observed, at active outpatient follow­up for certain groups of patients.

Aim of the lecture. To present the modern concept of etiology and pathogenesis of the intrahepatic cholestasis of pregnancy (ICP) and the modern diagnostic and treatment approaches to gastroenterologists. Summary. The etiology and pathogenesis of ICP are related to disorders of bile acid metabolism caused by hormonal factors (elevation of estrogen and progesterone levels) and genetic predisposition. The leading clinical signs of ICP include pruritus and jaundice that develop most commonly in the third trimester of pregnancy, and characteristic changes of laboratory scores: increase in bile acid level (over 10 mcmol/l) and moderate elevation of transaminase activity. Severity of ICP and complication risk for mother and fetus correlate to the degree of bile acids elevation. The most effective agent for ICP treatment is ursodeoxycholic acid (UDCA). Conclusion. Timely diagnostics of ICP and early UDCA administration, fetus condition control and early delivery at severe ICP cases allows to prevent development of serious complications and to achieve favorable pregnancy outcome.

Aim of investigation. To improve the short­term and long­term results of transsphincteric rectal fistulas treatment by patented two­stage method that includes elimination of fistulous tract with the subsequent enzyme treatment of the wound channel and delayed sealing by two­component biological glue. Material and methods. The method of cryptogenic transsphincteric rectal fistulas treatment is proposed. The method is based on elimination of fistulous tract by resection of internal lining. This is followed by sealing of the wound channel by biological glue which provides hermetic sealing as well as indirect stimulation of tissue regeneration. Treatment results of the patient group that matched inclusion criteria were analyzed: straight fistulous tract, absence of inflammatory changes and severe fibrosis in the area of fistula internal orifice. Prospective nonrandomized study which included 14 patients with cryptogenic transsphincteric rectal fistulas was carried out. At pre­hospital stage patients underwent transrectal ultrasound, fistulography and physiological tests. Results. Surgical intervention was carried out under local anesthesia, duration averaged 16 min (12 to 26), no intra­operative morbidity was registered. Pain intensity in postoperative period was minimal. Relapse developed in three patients (21.4%) of the 2nd, 3rd and 5th month of follow­up. Two patients (66%) underwent repetitive surgery by similar technique followed by complete elimination of the signs of disease. In one case at the 3rd month of follow­up transrectal ultrasound revealed the signs of relapse combined to ischioanal fat tissue leak that was probably undiagnosed at initial operation; reoperation was carried out - segmented proctoplasty by mucosal and muscular rectal graft. Assessment of anal sphincter continence after carried out surgery revealed no disorders. Conclusion. Surgical treatment of cryptogenic transsphincteric rectal fistulas by two­stage method including elimination of fistulous tract followed by wound channel enzyme treatment and sealing by two­component biological glue allows to achieve good clinical effect at strict indications and rectal sphincter sparing. Its lowinvasiveness and minimal tissue traumatization provides decrease in postoperative morbidity rate and decreases patient rehabilitation time. At repeated administration of this method the recurrence rate decreases to 6% at preservation of anal sphincter function. Strict patient selection with transsphincteric rectal fistulas and careful preoperative investigation allow to improve treatment results due to technical simplicity of the method as well as due to low complication rate both in early, and in remote periods.

Aim of clinical case presentation. To evaluate potential of intraluminal endoscopy for the treatment of diverticulitis, complicated by paracolic abscess. Summary. The clinical case of complicated colonic diverticula treatment by intraluminal endoscopy is presented. Patient at urgent admission was diagnosed to have “strangulated postoperative ventral hernia”; however the complex laboratory and instrumental investigations revealed inflammatory infiltrate in the right iliac area with signs of abscess formation. Attempts to carry out abscess drainage under ultrasound control were unsuccessful. To rule out potential neoplastic disease and determine the scope of surgical intervention videoassisted colonoscopy was carried out that revealed ascending colon diverticulum as a cause for paracolic abscess. Results. Endoscopic procedure provided successful surgical intervention that resulted in adequate internal drainage of the abscess was subsequent resolution of inflammatory infiltrate and complete patient recovery. Conclusion. Internal endoscopic drainage of the paracolic abscess that developed on the background of colonic diverticulitis can be successful alternative to urgent surgery due to reduction of treatment cost and improvement of quality of life of patients.